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Nurse Education, Expansion, and Development Act of 2007

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Addressing the Nursing Shortage:
Nurse Education, Expansion, and
Development Act of 2007
Omar Abdelghany
Farida Reyes
Mandy Reynolds
Monica Schlaich
Meghann Shannon
The Nursing Shortage
• The total number of nurses working in the field has decreased from
2,669,603 in the year 2000 to 2,262,020 in year 2001.
FTE Supply Implications of Changes in Projected Number of New
Graduates from U.S. Nursing Programs
Nurse Aging
Beginning of the Year
Congress Finds …
• Growing number of nurses with doctoral degrees
are choosing careers outside of education
• Average age of nurse faculty at retirement is 63.1
years (2006)
• Master’s & doctoral programs aren’t producing a
large enough pool of potential educators to meet
projected demand
• According to 2004 Monthly Labor Review of the
Labor of Statistics, more than 1 million new &
replacement nurses will be needed by 2012
Congress Finds …
• While the Nurse Reinvestment Act helped to increase
applications to schools, it has been unable to
accommodate the influx because of insufficient
numbers of educators
▫ 66.6% of schools had from 1 – 18 vacant faculty positions
в–« 16.7% of schools needed additional faculty, but lacked
resources needed to add more positions (2006-2007)
в–« 41,683 eligible candidates were denied admission due to
insufficient faculty (2005)
6 5!
NEED ACT: Capitation Grants
 S. 446, the Nurse Education, Expansion, and Development Act of
2007, was introduced on February 1, 2007 to amend Title VIII of the
Public Health Service Act, to authorize capitation grants.
 Capitation grants: are formula grants based on the number of
students enrolled.
 Administered by the Health Resources and Services
Administration (HRSA)
 grants may be used to hire new and retain current faculty,
purchase educational equipment, enhance clinical or audiovisual
laboratories, repair and expand infrastructure, or recruit
 Recipient institutions would receive the following for each student
enrolled: $1,800 per year for master’s/doctoral students, $1,405
for bachelor’s or entry-level master’s students, and $966 for
associate degree students.
 Currently ~ 40 programs that award competitive grants &
Capitation Grants
 From 1971 – 1978, Congress provided capitation grants funding
to schools of nursing in support of nursing education
 Nurse Training Act of 1971 (P.L. 92-158)
 Nurse Training Act of 1975 (P.L. 94-63)
 Capitation grants have had a stabilizing effect on past shortages.
 Also recognized as a strategy to resolve the nursing shortage:
 January 1974 – IOM cost study endorsed capitation grants as
an appropriate federal undertaking to provide a stable source
of financial support for nursing & other health profession
 March 2002 – HRSA’s Tenth Report to Congress on Health
Personnel in the US recommended capitation grants funding
as a strategy to expand the nursing workforce pipeline.
Eligibility to Participate
1) Accredited by a nursing accrediting agency
recognized by the Secretary of Education
2) Has a passage rate on the National Council
Licensure Examination for Registered Nurses of
not less than 80% for each of the 3 years
preceding submission of grant application
3) Has graduation rate of not less than 80% for
each of the 3 years preceding submission of
grant application
Maintain passage rate of not less than 80% on the National
Council Licensure Examination for Registered Nurses
Maintain graduation rate of not less than 80%
The 1st year enrollment of full-time students will exceed
enrollment for the preceding year by 5% or 5 students, whichever
is greater
Not later than 1 year are receipt of grant, school will formulate &
implement plan to accomplish at least 2 of the following:
Establish/significantly expand an accelerated baccalaureate
degree to graduate new nurses in 12-18 months
Establish cooperative intradisciplinary education with a view
toward shared use of technological resources
Establish cooperative interdisciplinary training between
schools of nursing & allied health, medicine, dentistry, etc
Integrate core competencies on evidence-based practice,
quality improvements, & patient-centered care
School will submit an annual report to the Secretary that includes
updated info on school with respect to enrollment, retention,
graduate & passage rates, employment, & number accepted into
graduate programs
School will allow Secretary to make on-site inspections & will
comply with requests for info to determine extent to which school
is complying
II. Historic Legislation and Policy
• Nurse Reinvestment Act: Passed by
President George W. Bush on August 1,
• The Reinvestment Act established:
Nurse Scholarships
Nurse Retention
Public Service Announcements
Faculty Loan Cancellation Program
• How does this tie in with the NEED Act of
Previous Legislative Efforts
• While the Nurse Reinvestment Act helped to
increase applications to schools of nursing
by 125 percent, schools of nursing have
been unable to accommodate the influx of
interested students because they have an
insufficient number of nurse educators.
Previous Legislative Efforts
• NEED Act of 2004
в–« 61.5% of schools of
nursing had 1-15
vacant positions
в–« 18,105 eligible
candidates denied
в–« Average retirement
age: 62.5; Average
nurse age: 53.5
• NEED Act of 2007
в–« 66.6% of schools of
nursing had 1-18
vacant positions
в–« 41,683 eligible
candidates denied
в–« Average retirement
age: 63.1; Average
nurse age: 54.7
Key Issues for Republicans
 Stance on governmental intervention on
Educational/Workforce issues:
 Belief that intervention should come from local &
• Under American Constitutional system, education
is a state, local, & family responsibility
• > 90% public school funding is at the state & local
 Role of federal government must be limited in
order to return control to parents, teachers, &
local school boards
Key Issues for Republicans
 Applicable Republican Principles:
 One of Republican principles states that “a
government must practice fiscal responsibility &
allow individuals to keep more of the money they
 Also that “the proper role of government is to
provide for the people only those critical
functions that cannot be performed by
individuals or private organizations, & that the
best government is that which governs least.”
Key Issues for Republicans
 President Bush’s Budget for FY 2008
 Requested 30% reduction in funding for Nursing
Workforce Development Programs (Title VIII of Public
Health Service Act)
 Funding went from $149.7 million to $105.3
 Advanced education for nursing which provided
support to ~ 12,000 graduate nursing students
was completely eliminated
 In area of nursing the only program whose
funding was increased was in research
Key Issues for Democrats
 Two of the three sponsors of the NEED Act
are Democrats and 32 of the 34 cosponsors
are Democrats.
 The nursing shortage is a national problem
so Democrats feel federal legislation and
funding should be enacted to help alleviate
the shortage.
Key Issues for Democrats
 There is not a lack of students, but a lack of
nurse educators to teach those students.
 As Dr. Harriet Feldman, dean of the
Lienhard School of Nursing at Pace
University and a strong NEED advocate said:
"Without a sufficient number of registered
nurses, patient safety is constantly
Key Issues for Democrats
 In 2004, more than 32,000 qualified students were
turned away from baccalaureate and higher degree
nursing programs.
 In 2006, 3,306 qualified applicants were turned
away from master's programs, and 299 qualified
applicants were turned away from doctoral
programs. The primary reason for not accepting all
qualified students was a shortage of faculty.
 Democrats believe that government must take
responsibility and interfere.
Key Issues for Democrats
• Congresswoman Nita Lowey: “My legislation
will increase the number of available nurses
by allowing nursing schools to invest in
more instructors and improved equipment
to increase their ability to enroll qualified
Implications of the Various Approaches
 Scenario 1: If legislation addressing nursing education and shortages is discouraged, we
are left with market forces.
 A catch 22: The further a market stays from being perfectly competitive, the more
unlikely that “natural” market processes will adequately address supply and demand
issues. Market-based solutions to the nursing shortage are unlikely to work
because of the existence of government regulation in the health care market, and
because of social views that it is a moral imperative that people receive care when
they are ill.
 Extra-market views about health care interfere with what market forces would provide,
making government regulation of the health care market necessary.
In a True Market
In U.S. Healthcare
If you don’t have money (insurance), you don’t
receive care.
Our societal (extra-market) views have yielded
safety nets, free clinics, emergent care without
insurance, etc.
The price of a good or service attracts exactly as
much demand as the market can currently supply.
There is an imperfect demand for services
because consumers are dependent on health care
plans, or in many cases have no coverage at all.
In economics, information asymmetry occurs
when one party to a transaction has more or
better information than the other party.
Consumers do not have perfect information about
the services that are available or what is best for
their specific needs.
Second best market in action, or
maybe more appropriately inaction.
 Increased regulations during the 1990s
 Decreased Medicaid and Medicare reimbursements.
 Profits were determined by Health Maintenance Organizations (HMOs)
 RNs were replaced by
 LPNs and Nurse Aides.
 The remaining RNs had new burdens
 Many nurses left the profession.
 Creation of a negative image of nursing as a profession.
------------------------------------------------------------------ Market Imperfections have exacerbated education pipeline issues.
 There are a limited number of nurses working in hospitals, nursing schools.
 Trouble matching students with clinical supervisors in the hospital.
 Plays a role in how may students schools accept.
Implications of the Various Approaches
 Scenario 2: For patient safety to be made a priority, legislation is
needed to fund enrolling more qualified applicants and hiring more
 While significantly more spending will be required to help reduce
the problem of the nursing shortage, hospital administrators also
must address all 3 dimensions of the problem before real
progress can occur in increasing the nursing supply.
 While NEED Act is a laudable step in the right direction, it
explicitly does not address the fundamental issues of work
conditions. These problems require that hospital administrators
and state and national policymakers expand their vision beyond
attracting more individuals into the profession.
 The NEED Act neglects reducing the high turnover rate in this
profession. The act must make sure the significant monetary
and resource investment in training new nurses produces a
lasting effect on the job market.
What Should We Regulate?
The national nursing shortage is a 3 Dimensional problem:
1. A declining number of new nurses entering the
2. Retention of nurses in hospitals.
Mechanisms to keep nurses in hospitals will address findings
that 40% of nurses working in hospital jobs report being
dissatisfied with their jobs, compared to other professions
where 10% to 15% of workers report dissatisfaction.
As long as hospitals under-staff their nursing units, require
nurses to float from unit to unit, require mandatory overtime,
and disrespect their nurses in general, the constant high
turnover in the nursing profession will continue.
3. Nurses retiring or leaving the workforce early.
The physical nature of nursing influences early retirement.
Hiring more assistive staff to help nurses, or having less
physical roles available to older nurses could keep nurses
working longer.
If the various views were to meet in
the Middle
 We would have…
Lets Not Forget About Texas
 Texas Nursing Reduction Act of 2001:
 Texas was one of the first states to address the
nursing shortage from a legislative perspective,
specifically bolstering the nursing education
 The Texas Nurses Association (TNA)
 wanted to develop a strategic plan for Texas
 TNA gathered partners
The Texas Nurses Foundation
The Texas Hospital Foundation
Texas Institute for Health Policy Research
The Greater Houston Partnership (economic research co.)
The University of Texas at San Antonio’s, Center for
Health Economics and Policy (CHEP).
Describing the Problem
 Texas’ research data confirmed that there was a
shortage, and attributed the Texas shortage to
these key factors:
an aging nursing workforce
an aging faculty workforce
a growing and aging Texas population
alternative employment opportunities for women
Intervention Arrives From Local &
State Efforts
The legislation attempted to addressed the key issues found in the
research conducted by CHEP. Legislation was responsible for:
1. Amending the current Texas Higher Education Coordinating Board
financial aid program for nurses.
2. Allowed greater flexibility in using funds to provide the number and
types of nurses that Texas would need in the coming years.
3. Provided nursing schools adequate resources to increase their
4. There was also a portion of the legislation aiming to encourage
innovation for recruitment and retention of students.
5. The policy provided sufficient faculty numbers by increasing the
salaries for nurse educators.
6. The policy planned to increase the number of nursing faculty by
providing two incentives for nurses to become nurse-educators:
First, granting colleges the authority to allow out-of-state graduate
nursing students the opportunity to pay in-state tuition if they agree
to teach at a Texas school of nursing after completion of their
advanced degree.
Second, by expanding the financial aid for graduate students going
into teaching .
Money, Money, Money
 An important part of the strategy by The Texas Nursing Association
was to identify money in the state budget to appropriate to the
nursing shortage.
 Dramatic Growth Fund with $22.5 million was made available to
schools of nursing. To access this fund, nursing programs had to
illustrate an adequate increase in student enrollment. These funds
could be used to support faculty salaries and as operating funds for
the nursing programs.
 The legislation reallocated almost$4 million from the tobacco
lawsuit, to be used exclusively for nursing education.
 Nursing Innovation Grants were created and funded through the
reallocation of tobacco settlements, which resulted in $2.4 million for
competitive grants. These grants focused on the recruitment and
retention of students.
 A smaller fund of $1.5 million was generated to pay faculty who teach
an over-load class
Legislation Impact In Texas
 Texas public schools of nursing saw a
18.9% increase in their enrollments between
the fall of 2000 and fall of 2002.
 This is particularly significant because the
national data during about this same time
period indicated only an 8% increase in the
enrollment in schools of nursing.
 Health science centers proved to be even
more successful by increasing their
enrollment of nursing students by 26.9%.
Fiscal Implications
 If you agree with the democrats, that the nursing
shortage is a national problem so federal
legislation and funding should be enacted to help
alleviate the shortage. Then either
 Taxes or the deficit will increase
 PayGo must be used, and funding will have to be cut
from somewhere else.
 If you side with the republicans that intervention
should come from local & state, and it likely would
have to given the president’s 2008 budget for
Nursing Workforce Development Programs, then
 There must be money to spare or costs to eliminate in your
state’s budget.
III. Proposed Legislation
• Amend the current NEED Act 0f 2007 to
include that funding would be used to:
в–« Pay nurse educators more money.
в–« Improve the work environment.
в–« Improve the physical options for older
• According to the Monthly Labor Review of the
Bureau of Labor Statistics, more that 1,000,000
new and replacement nurses will be needed by
• Surveyed nurses agree that improving nurse-topatient staffing will provide the best costeffective patient safety intervention.
Target Groups
• Nursing students
в–« Undergraduate
в–« Graduate
• Nursing faculty & educators
• Nurses currently in workforce
• Universities/Institutions providing
education to nurses
• New proposed legislation must focus on:
в–« Keeping nurse educators out of direct care
в–« Decreasing nurse turnover through having
necessary equipment and high satisfaction
• Nurse Educators:
в–« Entice nurse educators to work more in the
classroom setting by allocating money
specifically for their services
в–« Nursing schools nationwide are struggling to
find new faculty to accommodate the rising
interest in nursing
• Nurse Educator Services:
в–« Designing, implementing, evaluating and
revising academic and continuing education
programs for nurses
в–« Assuring quality educational experiences
that prepare the next nursing workforce
в–« Advising students
в–« Engaging in scholarly work (e.g., research)
в–« Participating in professional associations
• Nurse Educator Services (cont):
в–« Speaking/presenting at nursing conferences
в–« Contributing to the academic community
through leadership roles
в–« Engaging in peer review
в–« Maintaining clinical competence
в–« Writing grant proposals
в–« Evaluating learning
в–« Documenting the outcomes of the
educational process.
• Retaining Current Workforce:
в–« Between 200 and 300 doctoral-prepared faculty will
be eligible for retirement each year from 2003
through 2012, and between 220-280 master'sprepared nurse faculty will be eligible for retirement
between 2012 and 2018.
в–« The proportion of RNs with nursing doctorates who
were employed in nursing schools with baccalaureate
and higher degrees dropped from 68% in 1992 to
49% in 2000.
• Retaining Current Workforce:
в–« Clinical and audiovisual laboratories must be
enhanced so that nursing faculty has the
equipment and infrastructure they need
в–« Salaries must be raised because higher
compensation in clinical and private-sector
settings is luring current and potential nurse
educators away from teaching
BILL, which provides the authority for
a program or agency to exist and
determines its policy.
 It recommends spending levels to
carry out the defined policy, but
these levels are not binding.
 $75 million for FY 2005, $85 million
for FY 2006, and $95 million for FY
 Without increased federal support, the
potential for future growth in nursing
education programs may be limited at
a time when the demand for welleducated nurses is rising.
• Our legislation wants to follow up the 2002
Reinvestment act, by correcting why it was not the
end solution to the nursing shortage. because...
#1 To get more nurse educators, the pay must be
more than those nurses can earn in the community.
#2 Fix the work environment so nurses stay
working. That way the country will not need a
brand new supply every couple years. We must to
beat the rate of retirement and career change in
nursing with better conditions, not just new
The expectation is to see a dramatic improvement in the nursing deficit as a result of
our legislation. We hope for bypartisan support, as our legislation:
Will ensure that the 2002 Reinvestment Act was money well spent, by keeping the
nurses that act recruited and financed the education of happy and longevitious in
their jobs. Our legislation will help to apply the funding already made available for
nursing education, by creating enough teachers to expand school enrollment.
Our legislation is justified in its national breadth because this is truly a nation wide
problem that is not already, or adequately state legislated
п‚– According to the Department of Health and Human Services, the number of
states with a shortage of RNs is expected to only grow from 30 states in 2000.
By the year 2015, all 50 states will experience a shortage of nurses to varying
п‚– Presently, only four states have legislation to address the RN and nurse
educator shortage over the next 5 to 10 years. Four more states, including
Texas, have legislation for the shortage of nursing students and low nursing
school capacity.
п‚– Finally, as of December 2002, eight states had implemented laws or regulations
that ban or limit mandatory overtime.
Nurses for a Healthier Tomorrow. Nurse Educator.
American Associate of Colleges of Nursing. Dr. Harriet Feldman
Testifies Before Congress in Support of AACN’s Recommendations to
Alleviate the Nurse Faculty Shortage. 2005 Press Release.
American Association of Colleges of Nursing: Fact Sheet: Nursing
Shortage. March 2007.
Health Resources and Services Administration. What is Behind HRSA’s
Projected Supply, Demand, and Shortage of Registered Nurses? US
Department of Health and Human Services.
Henderson, Tim & Scanlon, Anna. Federal Title VII and Title VIII Health
Professions Training Grants: Their Importance in Improving Access
to the Health Workforce in Arkansas, Minnesota and Texas. March
Berliner, H. B., Ginzberg, E. “Why This Hospital Nursing Shortage Is
Different”. JAMA. (2002) Vol.288:2742-2744. Available:
Wagner, E., Brown, A. F., & Miner, M. “Addressing the Nursing Shortage
as a Market Failure”. December 7, 2005. Available:
American Associate of Colleges of Nursing. FY 2007
Recommendations: Support Capitation Grants Legislation. February
Kaiser Family Foundation “Addressing the Nursing Shortage”
American Association of Colleges of Nursing.
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